1. Field of the Invention
This invention relates to the field of healthcare transactions. More specifically, the present invention comprises a system and method for facilitating payment for a healthcare service transaction provided by a healthcare service provider to a patient, particularly where the payment is to be paid by an insurer.
2. Description of the Related Art
The rising administrative costs associated with providing healthcare services is a well-documented and growing problem for hospitals, physicians, patients, insurers and society in general. The United States currently spends in excess of 300 billion dollars per year for the administration of the healthcare system. Administrative costs continue to grow at a faster rate than the cost of the actual healthcare services. These administrative costs make healthcare more expensive for providers, patients, insurers, employers, and the government. In addition, these costs do very little to improve the quality of healthcare.
Although there are many inefficiencies in the administration of healthcare services that contribute to these extreme costs, a significant amount of the costs are associated with the administration and coordination of healthcare claims submitted to insurers and the subsequent response from insurers. In addition to being cost and resource intensive, the current healthcare transaction process lends itself to fraud and abuse. Because the current transaction process is complex, decentralized, and fragmented, it is difficult to detect and prevent fraud or abuse. This shortfall has created great additional costs to all.
As an example, the typical transaction process begins when a patient presents himself or herself to a healthcare provider. As part of the routine take-in procedure, the clinic or office collects information about the patient including the patient's name, address, contact information, and insurance information. This insurance information typically includes information about each of the insurance policies that provide coverage for the patient. This patient information is typically entered onto a Health Insurance Claim Form or decentralized data collection system. The patient is asked to sign a release, also presented on the Health Insurance Claim Form, granting the provider permission to release any medical or other information necessary to process the insurance claim.
The remainder of the form is typically completed by the provider or someone at the direction of the provider. This information often includes details regarding the diagnosis and services provided by the provider, including procedures and services rendered, supplies used, and the provider's usual and customary charges for the services and supplies. The provider also supplies their identification and other billing information required for the insurer to identify the provider and patient to the insurer.
The Health Insurance Claim Form is then forwarded to the insurer who initiates the adjudication and payment transaction process. Once received by the insurer, the form may change hands multiple times before the claim is ever adjudicated. The adjudication of the claim requires a claim specialist with knowledge of the covered patient's insurance policy to evaluate the diagnosis and treatment to determine if the healthcare services are covered by the patient's insurance policy. In some cases more information may be required by the insurer to make this determination, which the insurer may later request the healthcare provider to provide. If all or any part of the services provided are deemed to be covered, the insurer will provide payment.
The previously described process describes the simplest claim submission, adjudication and payment process. Even this simple payment transaction process takes a substantial amount of time and resources to complete. The process is even more complicated when there are multiple insurers or disputes regarding coverage. In the case of multiple insurers, an order of insurance must first be determined. One insurer is designated the primary insurer, the next insurer is designated secondary, and the next tertiary. This continues until there are no more associations in accordance with the industry rules. This order of insurance determination and subsequent coordination of benefits can make the payment transaction process take even longer.
This process of exchanging forms makes it difficult for parties to the payment transaction to valuate their respective accounts payable and accounts receivable at a given time. Providers are required to spend more time and resources to facilitate collections and insurers often lack the ability to aggregate liability data to detect fraud and other abusive behavior. The lack of transparency in the transaction process and the inability to compare performance and cost data undercuts the accountability of the parties and hinders the ability of the healthcare system to function efficiently.
Accordingly it would be desirable to have a payment transaction system that provides greater transparency for the parties involved, that provides a real time snapshot of services provided, liabilities incurred, and payments that are owed, and that reduces the administrative overhead as well as the time it takes to complete the payment transaction process.